Fillable Printable Form VS-117 - Application for a Motor Vehicle Body Damage Estimator License - New York
Fillable Printable Form VS-117 - Application for a Motor Vehicle Body Damage Estimator License - New York
Form VS-117 - Application for a Motor Vehicle Body Damage Estimator License - New York
APPLICATION FOR A MOTOR VEHICLE
BODY DAMAGE ESTIMATOR LICENSE
FOR OFFICE USE ONLY
EIA EIO EIC EIS EIG EID
License Number County
OE ADD
Y N N Y
RETURN APPLICATION AND PAYMENT TO:
BUREAU OF CONSUMER AND FACILITY SERVICES
PO Box 2700-ESP
Albany NY 12220-0700
Telephone (518) 474-7998
FOR ORIGINAL
APPLICATIONS
Answer ALL questions on pages 1 and 2 that apply to you, and SIGN the application on page 2. An estimator’s license
will be issued only to someone who has: at least one year of training and/or experience in body repair cost estimating for a
registered repair shop; or at least one year of training and/or experience in adjusting body repair claims for an insurance company
or independent adjuster; or a degree in automotive technology from an accredited college or university or vocational school, and
at least six months of experience in body repair cost estimating for a registered repair shop.
ORIGINAL APPLICATION FEES
Non-refundable application fee. . . . . . . . . . . $ 25
Three-year license fee . . . . . . . . . . . . . . . . . . $150
Total amount due. . . . . . . . . . . . . . . . . . . . . . $175
Each fee must be paid with a separate check or money order
payable to the Commissioner of Motor Vehicles.
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Check type of application:
o ORIGINAL o AMENDMENT (No Fee) o REPLACEMENT (No Fee)
Have you ever been a Certified Motor Vehicle Inspector and/or a Licensed Body Damage Estimator?
o Yes o No
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TO AMEND OR REPLACE YOUR ESTIMATOR LICENSE
Answer questions 1-20 below, and SIGN the application on page 2 (No. 24).
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If “YES”, give your Certification/License No. _________________________________________
LAST NAME FIRST M.I.
DATE OF BIRTH
Month Day Year
/ /
M F
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Expiration
Date____________________
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MAILING ADDRESS NUMBER (include street no., rural delivery, and/or box no.) APT. NO. HEIGHT
Feet Inches
EYE COLOR
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MAILING ADDRESS STREET NAME HOME TELEPHONE NUMBER
(include area code)
( )
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CITY OR TOWN
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HOME ADDRESS (if different from mailing address)
NUMBER AND STREET (include rural delivery, box no. and/or apartment no.)
Has your address changed since your last driver license was issued? o Yes o No
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CLIENT I.D. NUMBER (from NewYork State driver license or non-driver ID)
NOTE: Failure to provide a valid Client ID will prevent issuance
of a Body Damage Estimator License.
CITY STATE ZIP CODE
STATE ZIP CODE COUNTY
VS-117 (10/15)
PAGE 1 OF 2
PLEASE CONTINUE, AND SIGN ON PAGE 2
If you are not licensed by the NYS Insurance Department, complete this form.
NOTE: Do not complete this form if you currently hold a NYS Independent
Adjuster’s License for General, Automobile-All Coverages, or
Automobile Damage and Theft Appraisal.
Please Print or Type in the spaces next to the arrows.
*VS-117*
o
Check this box if you do not currently have a New York State
driver license or non-driver ID. A form (ID-5 VSBDE) will be
mailed with instructions on how to obtain a Client ID.
www.dmv.ny.gov
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(FOR ORIGINAL APPLICATIONS ONLY)
Have you ever been convicted of any felony or misdemeanor?
o Yes o No If “YES”, give details below:
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(FOR ORIGINAL APPLICATIONS ONLY) List all motor vehicle body damage estimator experience:
(Applicants will not necessarily be rejected because of a conviction record. Each record will be reviewed on an individual basis.)
Date of Violation What is the Violation?
Employer’s Name and Address Type of WorkDates (From - To)
Date of Conviction Disposition & Fine Court Location
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(FOR ORIGINAL APPLICATIONS ONLY) List any trade school, vocational school, or other motor vehicle repair courses taken.
A copy of your diploma must be provided with this application if you have less than one year of work experience.
Section 398(d) of the Vehicle & Traffic Law authorizes the licensing of motor vehicle body damage estimators. Anyone who has such a license
agrees to comply with the rules and regulations promulgated by the Commissioner of Motor Vehicles. Failure to comply with these rules and
regulations may result in the revocation of this license.
Notify this office of any change in your address.
FALSE STATEMENTS MADE ON THIS APPLICATION ARE PUNISHABLE UNDER THE PENAL LAW.
School Name and Address Type of Course Type of DegreeDates of Attendance
SIGNATURE __________________________________________ Date_________________
(Sign Name in Full - DO NOT PRINT - No Nicknames)
NAME (PLEASE PRINT) __________________________________________________________
VS-117 (10/15)
PAGE 2 OF 2
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PRESENT EMPLOYER FACILITY NUMBER (if applicable)
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BUSINESS TELEPHONE NUMBER
( )
BUSINESS ADDRESS (NUMBER AND STREET)
CITY STATE ZIP CODE
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